Within the realm of narrative medicine on TV, Breaking Bad took us to a dark and violent place. The devastatingly brutal finale took the protagonist, Walter White – a cancer patient and chemist like no other – where he was destined to go from the start: he died. Walt had, from the first episode, a diagnosis of inoperable lung cancer. And he was human. So there’s no surprise, really.

What made the ending so memorable, besides wrenching, was Walt’s final surrender, to his circumstances. He accepted his impending death and decided, with what hours remained, to do some good. It wasn’t much, but he tracked down former friends and directed them, however forcibly, to provide for his son; he spoke honestly with his wife; he took a bullet.

a scene from the last episode, ‘Breaking Bad’ on AMC

Walt, a school teacher, got turned on to cooking crystal blue methamphetamine. He, a man who in the beginning could barely hold a pistol, became a ruthless killer. He called himself Heisenberg, after the physicist who established a principle of uncertainty. His new line of work led, indirectly, to planes crashing and body parts raining over his neighborhood. As a consequence of Walt’s choices in the fictional TV-years between his 50th and 52nd birthdays, other men’s daughters died, drug dealers died, crime bosses and old people and kids died. His world and home became ruinous. Until the end, he kept saying he was doing it, cooking meth for his family – that he might leave money for his wife, disabled teenage son and infant daughter.

In the end, he couldn’t repair his relationship with his teenage son, who’d idolized him. He couldn’t bring to life his former student and partner’s dead lover. Or resurrect others he’d killed along his strange, calculating and horrifying journey. Walt died in a bloody scene, right along with the professional bad guys, the hit-men he’d hired to get at others.

Someone close to me suggested the ending was “too good” – that Walt’s fit of honesty in an i-dotting finale offers a sense of catharsis, or redemption, that doesn’t follow from the antihero’s trail of heartless decisions. It was unlikely, he said. Unlike Heisenberg.

But I loved it. A lot. Mostly because in my real life, I’ve seen people nearing death who lacked the courage to contact loved ones, to say a few words that – while insufficient to fix what’s irreparable – might have helped them gain peace of mind, or future solace. On the other side, I’ve seen family members and long-lost friends afraid to call or visit patients on their death beds, for not knowing what to say, for not being able to set things perfectly right.

Sometimes there’s no way to mend a person or a bad situation. You can’t deny reality. But if you’re still conscious and able to communicate, you may be able to lessen the damage you’ve done, or the pain someone else is experiencing, just a bit.

It’s Shark Week, or at least that’s the situation over at Discovery Channel. The annual, virtual immersion into the world of cartilaginous fish has been adopted by your author as some sort of metaphor, but she’s not sure for what.

“Live every week like it’s shark week” is a puzzle. In fact, this statement in a 30 Rock episode lurks at the periphery of Medical Lessons year-round. By now I should confess I’ve never watched an entire Shark Week program. But that doesn’t stop me from wondering about the significance.

Remotely, it’s about mental health. Science, too. I could head into a discourse on cartilage and the alleged beneficial effects for illnesses like cancer, but I don’t believe there’s any evidence to support those claims. Surely, Shark Week has to do with whether you embrace more risk or take a safe route, swim where divers go or watch TV about nature. At another level, it’s about time – a reminder that there are only so many days and nights in each week, in each month, in each year, by which we mark our lives.

So it’s about mortality. Maybe.

An alternative theory is that Shark Week is entirely devoid of deep meaning. It could be nothing more than a tool by which the Discovery Channel turns a profit in August. This year, the event was delayed until August 12. Although I’ve never taken a course in cable network programming, I would hazard a guess that this scheduling change had to do with the end of the Olympics programming that same day.

For 2012, I’ve decided to celebrate Shark Week by not watching TV. Furthermore, I won’t write on anything that has to do with breast cancer or hard science. This morning, I walked to a beach and went for a swim before breakfast. It was fantastic.

Tracy Jordan: So here’s some advice I wish I would have got when I was your age… Live every week, like it’s shark week.

—-

Now, five years later, I still don’t watch the Discovery Channel by choice. And I’m afraid of sharks when I’m in the water in places where they might be near. Last season, I watched 30 Rock less regularly than before, not just because of Tracy’s frequent absence, but mainly for lack of time. Still, what I enjoy most on that show is watching Alec Baldwin, who continues to set a fabulous example of how a talented and handsome man can pick himself up after a rough patch.

Just yesterday I was swimming in the pool next to people in scuba gear practicing for the real deal. I wondered if they watch Shark Week, or live by it, somehow.

How have Tracy’s words influenced me?

Well, I’m determined to get my book done, to take care of my mind and body, and to enjoy part of every single day. No deep insight, really. But true, at least for today. Maybe next year, I’ll have a more interesting thought on the subject of Shark Week. I might even watch the program.

(Hopefully a second opinion)

When I last wrote on The Big C, a Showtime series in which the actress Laura Linney portrays a woman in her forties with advanced melanoma, I considered some of the options she might choose when the series resumes next Monday night.

Laura Linney, in Showtime's 'Big C'

At the end of Season 1, she elected to try a course of IL-2 as was recommended by her young oncologist. Meanwhile, the FDA has approved Ipilimumab (Yervoy), an antibody treatment that revs up the immune system. And she’s in line, according to the script, for possible entry into a clinical trial that likely involves a targeted therapy, like vemu­rafenib for patients whose malignant cells have a genetic mutation in B-RAF.

What I expect Cathy will do, before anything else happens and she receives any additional non-urgent treatment for her advanced melanoma, is get a second opinion. She’s a smart, sensible sort; in retrospect it’s hard to believe she didn’t do this earlier on and before starting the IL-2 therapy.

I wonder, also, if one of her family members or friends will do some research about melanoma on the Internet. That would help her find a doctor with appropriate expertise, and better know what questions she should ask of the oncologist during the consultation.

I’ve been toying with the idea of messing with a cable TV show’s plotline. At the first season’s end of The Big C, the story’s protagonist decides to accept a harsh and usually ineffective treatment for her advanced melanoma: interleukin-2 (IL-2).

Laura Linney as Cathy (Showtime image, The Big C)

Cathy, played by the actress Laura Linney, understands the goal is not for a cure, but to temporize her disease for six months, when she might be eligible for a new melanoma drug through a clinical trial. Her oncologist has already completed the paperwork, according to the old script. The season ends with Cathy in a hospital bed with an IV catheter, presumably receiving the IL-2, and dreaming.

So I thought I’d explain a bit on interleukins and IL-2 in particular:

Interleukins are proteins defined by their capacity to communicate between different populations of white blood cells (between leukocytes). The term was put forth by a group of scientists who studied lymphocyte activation in a 1979 paper in the Journal of Immunology. IL-1 was the first named interleukin, IL-2 was the second, and so forth.

IL-2 was first known as Lymphocyte Activating Factor (LAF). It went by other names, too, including Helper Peak, T-Cell Replacing Factor III, and B-Cell Activating Factor (BAF). It’s a powerful cytokine, a molecule that stimulates other cells to grow and mature. Most of it comes from T-cells. For decades, doctors have been aware of IL-2’s anti-tumor potential: it can stimulate the body’s natural killer, lymphokine-activated killer (LAK) and other cytotoxic cells to destroy malignant cells.

Now, human IL-2 is available in recombinant form. This means that researchers don’t need to purify the stuff from growing cells. Instead, companies use its genetic sequence to manufacture the protein in commercial labs, much in the way that other hormones are synthesized for medicinal use – like insulin or growth hormone. Recombinant human IL-2 is called Aldesleukin and sold as Proleukin.

When I was a resident and a fellow, I gave IL-2 to some cancer patients and monitored their reactions in clinical trials. It’s not an easy drug to take, as is emphasized in The Big C, set to resume on TV June 27.

The situation in Japan remains grim. I can’t reasonably report on this, except to say what’s evident by the photographs, videos and usually-reliable sources: a second reactor may have ruptured. There’s been another burst of radioactivity into the air.

Flickr, Official U.S. Air Force photo stream

Meanwhile, thousands of bodies are being discovered in the post-Tsunami landscape along the northeast coast. The Emperor’s speech adds a feeling of gravity, essentially unfathomable to those who are not there, and maybe even to those who didn’t live, first, through the atomic bombings in that country 75 years ago.

What to do with such knowledge as photographs bring of faraway suffering? …For all the voyeuristic lure – and the possible satisfaction of knowing, This is not happening to me, I’m not ill, I’m not dying, I’m not trapped in a war – it seems normal for people to fend off thinking about the ordeals of others…

People can turn off not just because a steady diet of images of violence has made them indifferent but because they are afraid…

She considers the role of TV, and the CNN effect regarding images from the war in Sarajevo, and says now (in the book):

The question turns on a view of the principal medium of the news, television…Images shown on television are by definition images of which, sooner or later, one tires. What looks like callousness has its origin in the instability of attention that television is organized to arouse and to satiate…The whole point of television is that one can switch channels, that it is normal to switch channels….

*in reality, her book-essay – on war imagery – grips with relevance, I sped through.

—

Probably by now, my dear readers are wishing I’d write on something else, and somewhere else, which indeed I am doing with most of my time now. But I think the real-time contemplation of the images – and why we look at them, or don’t – is valuable in itself.

And also, maybe it would help the people of Japan, there, to know that people are thinking about their plight.

“I don’t want to get sicker trying to get better and then just end up dying anyway” – Cathy, the 42 year old protagonist with advanced melanoma, on the Big C.

—

ML’s incoming search data suggest that some people out there are very determined to know exactly what happens to Cathy in Showtime’s new series about a young-seeming, middle-aged woman with advanced, presumably stage IV, melanoma. In last week’s review I elected not to give it away. Now I’ve reconsidered. So here’s a spoiler alert: Don’t read this post if you don’t want to know what happens to Cathy at the end of the Big C‘s first season.

After months of unusual and comfort zone-breaking behavior, Cathy reconsiders her initial decision to forgo treatment. She, possibly influenced and clearly supported by her husband’s enthusiasm for her middle-aged life and continued existence, indicates that she’s willing and ready to try treatment with Interleukin-2. Cathy seems to know something about the FDA-approved drug, which is generally toxic and ineffective in most melanoma cases. At one point, she lists its putative side effects, according to the show: “burning scabs all over my body, constantly throwing up, fluid on the lungs, my veins could shut down, I could die on the table…”

Nonetheless she decides to accept treatment:

“I’m gonna hang on as long as I can. And I’m going out ugly,” says Cathy, played by the actress, Laura Linney.

“It will never be hard for me to look at you,” responds her supportive husband Paul, portrayed by the actor Oliver Platt.

At this point Cathy’s hoping the Interleukin-2 (“interlaken,” as her husband keeps calling it, perhaps metaphorically, subconsciously, or else just simply) will keep her alive for six months, when she might or might not be eligible for an experimental anti-melanoma drug in a clinical trial.

So she goes for it: in the final scene she’s in the hospital, her mind cloudy, and dreaming. You may wonder what I think of her decision.

As an oncologist I’m half-relieved. The patient will, undoubtedly, die too soon – within months or a year or, if she’s lucky, maybe two years or even longer – because you never really know for sure about these things, if she doesn’t take any treatment. Deaths from metastatic cancer can be unpleasant and painful. On the other hand, conventional therapy for stage IV melanoma rarely leads to complete remissions and, essentially, never cures the disease.

I admired that the patient, until this last episode, maintained such a no-nonsense approach to her condition. Her perspective seemed more mature than her oncologist’s. Despite her weird and nearly unraveling behavior, she’s clearer in her priorities than many patients I’ve known; she seems to understand that a treatment might give her a few additional months but is very unlikely to help her get well and, likely, would make her sick for the duration of her life.

Sometimes oncologists get carried away with hope. What I liked best about the story is that she, the patient, was realistic in this. She didn’t want to take toxic medications in desperation, without reason.

As a patient, my feelings are mixed, too. I respected Cathy lack of passivity in her decision. Accepting treatment initially would have been the easier, “normal” thing in our culture. In effect, so far, Cathy’s taken control of what happens to her body. At the same time, I couldn’t help wonder – what if she tried it? Maybe there is a cure in the pipeline, and she’d be eligible for an experimental agent in a few months, and that drug would help her, and she’d live beyond middle age, or at least until she’s 45 or 46.

Today is Monday, but there’s no new Big C episode because the season’s over. We won’t know how Cathy fares with the Interleukin-2 for a while. Even though she is just a cable TV character, she’s in a position to teach us about oncology and living with cancer.

Hopefully the show’s producers will provide insights into immune treatments, targeted agents, clinical trials, informed consent and palliative care. (I will consider Interleukin 2 and melanoma in a separate post, to follow.) But given the TV scenario, do you think Cathy’s made a sound decision?

Last night I stayed up to watch the first episode of Laura Linney portraying a middle-aged woman in a new series called The Big C. The story is that she’s got a teenage son and a recently estranged, overweight husband who loves her. She lives in a suburban house that could use some work. She teaches in a high school. She has a brother who’s deliberately homeless.

Her name’s Cathy – how ordinary can you get? Well, Cathy recently found out she has a terminal case of melanoma. In a change of pace, she expresses herself freely and does pretty much whatever she feels like doing.

For me, this TV situation has some big draws:

Laura Linney‘s a fine, not uninteresting actress. A few years ago she played a charming Abigail Adams in a history-minded miniseries. But I couldn’t bear to watch her miscast counterpart, Paul Giamatti, pretending to be President John Adams, so I didn’t. As in the storyline of the Big C, here’s an opportunity for Linney to shine.

Gabourey Sidibe, a young obese woman who stars in the movie Precious, may or may not be a fantastic figure on film or TV. She’s yet to be established beyond her debut and after watching last night’s episode I’m concerned already that she’s being “used” as an object for the protagonist’s preterminal beneficence. Still, she’s a definite plus.

The Big C‘s plot includes at least two “atypical” and potentially complex features. First, Cathy chooses not to take chemotherapy or other treatment. This intrigues me, and may be the show’s most essential component – that she doesn’t just follow her doctor’s advice. Second, she doesn’t go ahead and inform her husband, brother or son about the condition, at least not so far.

We’ve seen this non-communication before in movies (Susan Sarandon in Stepmom, for instance) and in real life, for most of human history. It’s too-easy for a blogger-patient-oncologist to forget that not long before our Facebook era, most people didn’t talk much about having cancer and even today, many patients prefer not to do so. Norms change.

If the point of the Big C is to broaden the dialog on cancer and talking about cancer, that’s worth a lot, still.

What’s wrong with the program? I think the doctor has some brushing-up to do about his image. He’s 31 and Cathy’s his first “case” – all of which is credible, but with the exception of an x-ray briefly revealed on the wall-mounted light-box, it’s not clear if he’s an oncologist or a dermatologist somehow offering her chemotherapy and pamphlets. His white coat is too short, in the style of a medical student’s. He uses few polysyllabic words. He looks well-rested and neat. In one strange scene, the patient and doctor meet for lunch at a pleasant outdoor restaurant. That’s not how oncology’s practiced, at least as I know it.

But I’m learning, too. And I’m wondering about the informational content of the doctor’s slick handouts, about which the protagonist, Cathy, has a vision.

A few months ago I wrote that I’d take another look at Nurse Jackie, a ShowTime series about a drug-addicted ER nurse and mother. The posters, featuring Edie Falco as the program’s heroine, caught my eye; she’d charmed me in her previous role, as Carmela Soprano. Besides, this story’s set in NYC. The hospital is vaguely-modeled upon St. Vincent’s Medical Center, a recently-shuttered Catholic Hospital in Greenwich Village.

Out of some sense of compulsion, wanting to provide careful follow-up to my readers, I forced myself to watch each episode before completing this review. Unfortunately I found the series so unpleasant, besides uninteresting, that it took me months to plod through my assignment.

Jackie is supposed to be a crackerjack nurse who has some serious problems including drug addiction. That premise might be fair enough, in a House-like way, if her life-saving skills had unique value. But they don’t: the underlying problem with this show is that Jackie has no exceptional or redeeming qualities as a nurse. Sure, she cares about some of her patients, but that’s nothing extraordinary. Rather, she stands out by lying, making up results and, not infrequently, cutting out when and where she’s needed.

The emergency department where Jackie works is supervised by a not-quite indifferent administrator portrayed disappointingly by Anna Deavere Smith, whose real talents reach far beyond the realm of the petty disputes and not-unusual life issues that plague this TV hospital’s staff.

As a physician-blogger who’s trying to understand the potential value of Twitter in health care, I thought perhaps I might learn from the show’s ER doc Cooper’s social media skills: he tweets while working, nominally as a physician. But he’s presented as such a vain, stupid twit that he’s just not credible as a doctor of any kind. Even his Tourette’s tics are adolescent – he grabs women’s breasts when stressed, a curious behavior that seems, if anything, to suit the show’s shallow drama more than any real patient’s disease.

Plenty of TV shows have offered insights on health care delivery by quirky, self-absorbed and sometimes-deluded workers with interpersonal issues and stress (think M*A*S*H, for starters). But this series doesn’t make that grade. There’s no adult humor, no attempt at medical mystery-solving or even a good, old-fashioned medical ethics quandary. Unlike the Sopranos‘ story, here most of the characters bear little depth. Jackie’s multiple psychopathologies are a vile, exaggerated example of a woman juggling too many things, badly.

So I was surprised to find out that Jackie’s contract was renewed. Even more, I wish that the real St. Vincent’s Hospital, which once provided care to me and, over the years, helped countless other real New Yorkers, were still open.

I won’t revisit this show. But I’m looking forward to The Big C, which starts on Monday. Hopefully that will deliver better entertainment, or at least some fresh ideas.

Nurse Jackie’s back on TV tonight. I know this because when I logged on to the New York Timesthis morning her ad flashed right at me, front page and right center. She’s displayed prominently on Huff Po, vanishingly on Dictionary.com. With just a quick search I can’t find her anywhere in the Wall Street Journal. At the LA Times she takes over the screen.

Poster for Nurse Jackie, Season 2

(As an aside, on the shifting nature of medical information, most future readers of this post will not know for sure if what I’ve described about the present on-line positioning of these commercials for TV is true. The same happens in practicing medicine, when clear signs of disease – like abnormal crackles on a lung exam – can be fleeting, leaving no digital or even a film imprint, yet very real. So you’ll have to trust me, or take no value from this depiction.)

For the “facts” on Nurse Jackie you can find her on Showtime’s original website. There, the program promises to continue “its look deep inside the complicated heart and soul of a functioning addict, a loving wife, mother, and a first-class nurse.” I’m curious but must admit that last year I watched only part of one episode and didn’t return.

Back then I was turned off preemptively by the image of Edie Falco looking harsh, white-coated and unsmiling. The syringe and needle in her raised, gloved hand suggested a third finger, or at least that’s how it seemed as we drove past her image, repeatedly, on a giant billboard. That poster was enough for me. I’d spent too much time in hospitals in trust of innumerable nurses to want to see that side of health care delivery.

But today she beckons, half-smiling, an aura of pills and syringes above her head. Maybe she’s happy about the health care reform bill’s passage last night, but I don’t think she could have known about that when the photo was taken, or in her TV unreality world, that legislation matters. What’s clear is that Nurse Jackie looks warmer, tired maybe from her work. She’s appears ready to help someone, a stethoscope slung over her neck. Her right arm is raised, like in last year’s pose, but gentler, calmer. It’s no accident the poster heralds a “Holy Shift.”

Back to reality –

This morning I was listening to WNYC while reading the newspaper and eating my healthy breakfast. As I recall, according to a reporter assigned to assess the public’s and health care workers’ response to the health care reform bill among people on the street near Lenox Hill Hospital, in my neighborhood, one individual said she doesn’t really know what to expect from the changes because she gets most of her news from TV. I didn’t catch any more details – if she meant CNN, for example, or Fox or The View – and exactly how and why she found the source limiting.

One thing I did note in the Times, and also on the Kaiser Health News website, both of which provide excellent summaries of the hopefully-real health care changes to come, is that reform won’t even start to happen for the most part until 2014. Meanwhile grows an authentic addiction to the Internet, TV, radio and even some blurry advertisements for information on medicine that people can’t or don’t get elsewhere.

So I’m thinking I should watch Nurse Jackie tonight. Give it another try. Maybe I’ll learn something. And whatever did happen to the House of God?

In the latest episode of The Office, Kathy Bates walked into the Scranton branch of Dundler Mifflen and onto my living room TV screen as Jo Bennett, CEO of Sabre, a fictitious Tallahassee-based company. An assistant and two large canines accompany her as she meets the crew. She’s firm, graying and very much-in-charge.

When the camera gets her alone, in focus, here’s what she has to say:

“I’m Jolene Bennett, Jo for short.

I’m a breast cancer survivor, close personal friends with Nancy Pelosi, and Truman Capote and I slept with three of the same guys. When I was a little girl I was terrified to fly, and now I have my own pilot’s license.

I am CEO of Sabre International and I sell the best damn printers and all-in-one machines Korea can make.

Pleased to meet ya.”

(from The Office, Season 6, Episode 16, “A Manager and a Salesman”)

—–

Jo’s words are clear, delivered with eyes straight at you. It’s hard not to wonder what’s the significance of her being a breast cancer survivor, on the show and to her audience, and why she lists this alongside her other achievements in a highly-accomplished, fabricated life.

Kathy Bates is not the first actress to portray a woman who’s had breast cancer, and Jo Bennett is hardly the first TV character who’s had treatment. But this introduction seems like a perfect, even targeted strategy to revisit the topic:

What’s the significance of being a breast cancer survivor in 2010?

Maybe Jo’s a warrior, veteran-like, hardened after battle. Or perhaps wounded, deeply, now guarded by the dogs and a fierce resume.

Does she feel entitled? Bitter? Seek pity? Bates doesn’t play it in any of these ways, at least not in this first airing.

She has a mock-biography, Take a Good Look, I’d like to read. From the pseudo-Sabre website:

“A trailblazer in the world of electronic office equipment, Jolene Bennett serves as the President and Chief Executive Officer of the Sabre Corporation…Mrs. Bennett has received awards and recognitions, including being named one of Enterprising Women‘s Magazine 25 Most Influential Executives of 2007 and being named as a finalist for Tallahassian of the Year by the editors of Tallahassee Magazine in 2005.

Mrs. Bennett, a former Southern beauty queen, knows the importance of giving back. She has also received numerous awards for her philanthropic efforts with, among others, the Negro College Fund, The Florida Great Dane Rescue Society, and the American Breast Cancer Foundation. As a breast cancer survivor herself, Mrs. Bennett is especially passionate about helping other strong women beat cancer the way she did…

Jo’s company’s name is pointed. A sabre is a sword of sorts, usually curved, thick and sometimes lethal. My mind wanders to saber-toothed tigers, ferocious and extinct. And then, of course, to the Sabra, a native Israeli like a prickly pear – sharp on the outside, sweet beneath the rough skin.

I have no idea where The Office is headed with this theme, nearly ten years since Barbara Ehrenreich’s “Welcome to Cancerland” and roughly five since Elizabeth Edwards started her first chemo sessions.

I’m struck by how little talk there’s been of Jo’s mission since the episode’s debut. I’ve read dozens of blogs, TV reviews, there’s nothing. The Great Danes get mentioned, but not the breast cancer. Are we inured to the subject?

This isn’t about big Pink and ribbons. I’m talking about real patients who get tumors and need treatments. Some get depressed. Some die. Stuff happens.

As an oncologist, I saw women respond distinctly to their surgeries, radiation, chemotherapy and other treatments. Besides, the tumors vary in themselves – responding, sometimes lingering, killing too often. Some people need lots of medical care, others skate through.

There’s no right answer here, no one size fits all.

Regardless, I can’t wait to see the show’s next episode. Pam’s having a baby, life goes on.